Through a circular, Rajshahi University commissioned the researcher for compilation of the thesis titled " Psychosocial Factors related to Health Care Behaviour of the rural people under Rajshahi Division" and here is the outcome to that. Oxford English Dictionary’s brief definition of ‘psychosocial’ as ‘pertaining to the influence of social factors on an individual’s mind or behavior, and to the interrelation of behavioral and social factors’. This definition is likely to have important implications for social epidemiologists and other health researchers, because it implies that psychosocial factors, at least in the context of health research, can be seen as: (1) mediating the effects of social structural factors on individual health outcomes, or (2) conditioned and modified by the social structures and contexts in which they exist. The definition thus raises the question of what the relevant broader social structural forces are, and how such forces might influence health through their effects on individual characteristics. To our mind this is a useful working definition of ‘psychosocial determinants of health’. In fact, it would imply that psychosocial explanations of health might be more accurately referred to as ‘social-psychological’ explanations of health.
The term ‘psychosocial’ is also quite widely used in the literature in connection with health outcome. The roots of ‘psychosocial health’ lie in the World Health Organization’s (WHO) definition of health as ‘a state of complete physical mental and social well-being, and not merely the absence of disease and infirmity’.
To further elucidate the role of psychosocial factors in health research we suggest a distinction between macro-, meso- and micro-levels as a useful sociological framework. We regard psychosocial as a meso-level concept, just as religious institutions, the family, the firm, and the club is meso-level social formations. These exist at a level below and are modified by macro-social structures that relate to ownership and control of land and businesses, legal and welfare structures, as well as distribution of income and other resources between groups and individuals.
In the context of health research meso-level psychosocial concepts, such as social networks and supports, work control, effort/ reward balance, security and autonomy, home control, and work-family conflict are all produced within meso-level social formations. All these are manifested in interpersonal relationships. Thus, psychosocial explanations of health are essentially viewed here as processes that cannot be fully captured by single measures at one level, but require due attention to macro and micro (individual) level factors as well. However, not all processes from macro through meso to the individual micro level are psychosocial.
To our mind a central constituent of a psychosocial explanation of health is that macro- and meso-level social processes lead to perceptions and psychological processes at the individual level. These psychological changes can influence health through direct psychobiological processes or through modified behaviors and lifestyles. However, many psychosocial exposures such as unemployment (so called ‘stressful life-event’) and social networks/supports need not necessarily invoke psychosocial processes or require psychosocial explanations.
For investigating psychosocial factors for health care behavior, we have to take care of several “social factors” that affects or influence individual’s mind or behavior.
Various socioeconomic factors are of importance as those affect their health care behavior and practice levels. Among them anthropological history, traditional beliefs, economic conditions, education, communication, superstitions, social and religious customs, gender and prevailing facilities etc. are seems to be important. Poverty, population boom and low literacy rates have notable influences on the health care behavior of the individual.
The researcher assumed that certain social factors are affecting mind of the individuals and thus related to their health care behavior. So, the researcher conducted the study through investigating the existing Knowledge, Attitude and the Practices (KAP) of the rural population under Rajshahi Division in the contexts of health and attempt was made to relate them with the social factors mentioned.
Health care behavior denotes an action taken by a person to maintain, attain, or regain good health and to prevent illness. Health behavior comes from a person's health beliefs.
Health behavior of a population depends on its tradition or traditional beliefs. Bangladeshi people’s tradition is enriched by the influx of different religions, races and cultures on its soil for thousands of years.
Influx of the races in a country is important. People from different races and religions inhabited this land and they registered their culture, norms and traditional beliefs among the entire population, thus Bangladesh can be termed as the melting pot of races. Proto-Australoids or “Vedda”, Mongoloids, Mediterranean Caucasoids (Aryans) and also the Armenoids (of Indo-European stock) are believed to have entered as well. Muslims invasion started in the 8th century AD, new elements were introduced; persons of Arab, Persian, and Turkish origin moved in large numbers to the subcontinent. By the beginning of the 13th century they had entered what is now Bangladesh.
Bangladesh also contains tribal population. Most of the tribal peoples of Bangladesh inhabit the Chittagong Hill Tracts in the southeast, the least densely settled area of the country.
The rest of the people are Bengalis--an ethnic as well as a linguistic group. The Bengalis, however, are not homogeneous in origin. In general, the people of the coastal areas, with who the Muslim merchants of the Middle East were in close touch, show physical features that seem to be the result of the admixture of local people with those of Turkish and Semitic origin.
They all contributed in the organization of culture, customs and traditional beliefs, and the traditional belief is a component that affects individual mind and behavior, thus influences health care behavior significantly.
For Bangladesh, public health delivery systems is critical, especially in the Bangladeshi rural areas, where large proportion of people (70% according to Federal Research Division, Library of Congress, U.S. Department of the Army, 1986-1998) has been almost compelled to depend on medieval health care system in many respects. Lack of literacy and extreme poverty limits their options for modern health care practices, whatever existing in the government and private sectors.
Their response to diseased or sick conditions or their health care behaviour is the cardinal focus of the present study.
When sick, a person’s natural response is to seek remedy. They are trying their best according to their knowledge, attitudes and capacities to achieve, maintain, or gain the healthy status. When sick, whether they seek remedy and how? Where do they go for that? Are they very much keen for the modern treatment or prefer indigenous or alternative medicines?
In short, these are the effects of the social factors affecting their mind, resulting in their behaviour for practice.
Tradition, financial condition, literacy, religion, degree of flexibility, culture, social customs and manners, prevailing prejudices and superstitions in the rural society, fanatics or extremism of any nature, gender along with personality variations etc. are the key factors play important role to form, maintain and modifying these behaviours. They are developed, nurtured or modified in the social interaction within the society and they are termed as psycho-social factors related to one’s health care behaviour.
For Bangladeshi rural population and society, the factors vary very widely due to complex nature of the community.
So, in every steps of this study, researcher had to keep in mind of the myths, histories, tales, legends, social and religious conflicts, influences of the appeared nations in these soils and their cultures and traditions etc. while compiling the findings and the report.
The objectives of the study were:
1. To explore the health care behavior of the rural people under Rajshahi Division through investigation of their existing knowledge, attitude and practices in the health context and understanding their relation with different social, cultural and economic factors, values, beliefs and practices etc. prevailing among the rural population under Rajshahi Division those influence the individual for shaping the health care behavior of the rural people.
2. To investigate the disease trends, home management, extents of traditional and home management, source of information, traditional remedies and their relation with different social, economic and cultural factors etc. among the rural population under Rajshahi Division.
3. To understand the extents to which different social factors like economic status, literacy rate, religion, profession, health status, distances from hospitals, gender, associated stigma etc. affect individual’s health seeking towards the health service providers.
4. 4. To assess the knowledge, attitude, practice, perception and practice levels of rural population under Rajshahi Division towards etiology, course, and management of common diseases. To assess their preferences, satisfactions and role of the different service providers and their service extents.
5. To have an understanding of the social cohesiveness and emotional environment existing between the service providers and the recipients.
Rationale were:
i) Despite increased focus on medical and epidemiological aspects of health and disease, researches on psychosocial and behavioral factors were not adequately addressed.
ii) Findings of the study are expected to help health service planners for their designing of appropriate service delivery system for the rural population. Social, cultural, economic and other factors revealed in the study may be of help for the policy makers and NGOs for advocacy.
The information revealed by the study would help us to design a cost effective welfare health service for rural Bangladesh by valuing their indigenous and traditional beliefs and values.
iii) The study would fill up the knowledge gaps regarding the views from the communities, so that the knowledge can be used in future planning of rural health system and in other researches.
iv) The study would also prescribe the idea how health care services can be better and effectively extended among the rural poor within our limitations as well as indicating how health professionals can improve the present environments in the service facilities.
Significance of the study would be an exploration, tracking and studying the health care behavior of rural people for unveiling the real situations, truths, problems and the scenarios that can guide us to solve many problems in the health sectors, especially towards developing a strategic health service delivery system for Bangladesh emphasizing optimal health service delivery to the vast rural population. Frequent experimentations are not suitable for a country like Bangladesh.
The main mission of the study was to explore and identify the interwoven social/cultural/religious etc. factors associated with the prevailing behavioral patterns of the Bangladeshi rural populations towards their health care. The main challenges of this study are the vastness of the area of the study, ii) extracting the information in the contexts and to document that without biasness from the bulk of the legends, tales and myths in their society.
Policy makers and donors’ interest in the study are as follows:
i) The study have importance as it was capable of unveiling factors associated with diversified ranges of health care behavior among the rural Bangladeshi population and the relation with the traditional beliefs, social, cultural and religious customs and manners. If those factors can be explored and documented, the donors can understand the points of interventions with ease and can do their best for utilization of their money.
ii) ii) Information derived from the present study would enable national and local level policy makers to design, compile and execute appropriate programs to establish a cost effective and people oriented health service delivery system.
iii) iii) Donors or “development partners” of Bangladesh, the westerns now days want their money to be spent in a participatory manner, i.e. with people’s participation. This study recorded the voices of the field, thus satisfies most of the requirements of the international donor community. As a result, it can be expected that donors will be interested in the present study for considering its findings/recommendations for their programs.
As per the methodology, the researcher decided a study directed for generalized exploration, tracking and documentation of the Knowledge, Attitude and the Practices (KAP) of the sampled rural population under Rajshahi Division and to understand the their relations with the social factors those affect mind of the individual and precipitate in health care behavior. As the behavioral studies are rare and the health behavioral studies are rare in Bangladesh, even in the region, it is assumed that the best would be a study for generalize exploration, tracking and documentation of the whole issues raised at first. In future, interested quarters can conduct studies more specifically in the sub-contexts to reach more depth. As a health behavior study is always a very vast study, the researcher felt logical to conduct a general study first to identify different sub-contexts in the hope that those could be studied by interested quarters in future. Also ethically the first studies should be the generalized followed by the more specific studies looking after the secondary findings. So, as a vast study, the researcher designed it with possible simplicity. Literatures and secondary data in the contexts whatever are available for the health behavioral studies were reviewed to find the knowledge gaps and to focus those in this study.
The focus of the study was the generalized investigation of situation in the rural Rajshahi Division in contexts of health care behaviors of the rural population and to understand its relation with the factors which had been found.
In-depth interview of the sampled rural population was designed and conducted through questionnaire is capable of yielding desirable information in the contexts.
For the KAP, a total of 348 interviews from 348 rural respondents found to be statistically sound and valid to represent the rural Rajshahi Division. Among them, 248 respondents were sampled from Rangpur District for representation of Rajshahi Division typical rural population and another 100 from Kurigram to fill the ethnic gap if there’s any.
Stratified random sampling, systematic random sampling, and purposive sampling techniques were used to draw the respondents.
The study area was the Village of Golau in Mouza Goalu of Union of Uttam in Rangpur Sadar Thana of the district of Rangpur and villages of two Thanas of Kurigram District.
Elaborate and proper arrangement was done for the purpose data collection and management.
The whole operation was conceived to entail three steps: planning, procedures and monitoring (or quality control).
Monitoring of listing/data collection work has been ensured in different ways. Checks, back checks, accompany call etc. mechanism were used for quality control of the data collected:
As the study design was an “ethical study design”, the confidentiality was kept through universally recognized rules. Data collected from the respondents were kept fully confidential, sensitive issues were avoided, always code numbers were used in data managements and in all references instead of the name of the respondents, no body was allowed to access the information except University authority and all the interviews were conducted with the informed consents of the respondents.
Data management consisted registration of schedules, editing, coding, and computerization, preparation of dummy tables (tabulation plan), analysis and matching of data and the researcher undertook the responsibilities. Computerization carried out through designing of program in SPSS/PC 12.0 by the researcher himself, data entry, data cleaning (by validity check, consistency check, etc.), report/table/information generation and printing and taking backups for further/future analysis were performed by the researcher himself.
Report was prepared with frequency tables (as per the recognized statistical rules), followed by write up. Statistical tests (t-test, chi-square and correlation) were used for assessing the significance of difference between two sets of data for drawing inference whenever felt necessary.
Dissemination strategy was planned for emphasizing the objective related issues for making the information useful to the potential users -emphases were given to highlight the most significant but solvable problems unveiled by the research. Both printed hard copy and soft copy in the CD were submitted to the supervisor Professor and University of Rajshahi. Researcher hopes that disseminate the report and the data through multiple approaches using a variety of channels to maximum number of audience/ readers after its final acceptance by the University of Rajshahi authority for the benefit of human civilizations and to add a little more to the existing knowledge of the mankind.
As per the general rule, primarily, the whereabouts of the study including findings was presented through a report as per the given outline by the supervisor.
For the planned in-depth interview of the sampled rural population for qualitative data, data collection instrument had been designed carefully as a qualitative questionnaire with mostly unstructured questions and general outlines of the topics. Clarifications were obtained by skillful follow-up questions. From the very beginning, the respondents were kept carefully unprovoked and no leading questions were put. Biasness was carefully avoided. They were totally free to discuss their topics in their own language and deployment of local females made the interactions even easier. Interviewers just tried them to keep in the topic tracts and not to deviate much except when necessary.
Socio-economic and demographic information revealed was as follows: 71.8% respondents were from Rangpur District and the rest 28.2% from Kurigram. Rangpur Sadar Thana accounted for the highest number of interviews (71.8%), Rajar Hat and Ulipur Thana, both within Kurigram District, were accounted for about 14.4% and 13.8% interviews respectively. Uttam Union of Rangpur Sadar Thana was accounted for the highest number of interviews (71.8%), Chhinai Union of Rajar Hat Thana and Pandul Union of Ulipur Upazilla, both within Kurigram District, accounted for about 14.4% and 13.8% interviews respectively. About 37.4% live in Goalu, 34.5% is from village of Bahadur Singha, Purbo-Debottor and Joykumar both accounted for 7.2% and Apuar Khata and Paschim Apuar Khata accounted for 6.9% respondents. About 51.7% interviewed were female. Mean age was 44.4 years. The highest aged was/were of 62 years and lowest of 30 years. About 8.9% was Pundro-Khastrio/Rajbanshi/Kuch1, 74.4% and 4.3% was Muslim and mainstream Hindu, Bairagi/Nath-hath-yogi/Baisnab2 and the Khyan were accounted for 5.2% and 7.2% respectively. About 44.5% were illiterate. Again about 32.2% were literate to the extent of primary level. Only 5.7% were educated up to the S.S.C. level and above. About 2.3% had physical disabilities. About 34.5% had number of family members as 4, 17.2% had 8 member families. About 29.3% belonged to agriculture as occupation, 46.6% were housewives. About 65.5% respondents’ economical condition was assumed as “not good”. About 58.6% had the income from agriculture, 20.7% related to the small business. Low-graded services contributed for 13.8%. Mean family income earning per month were seen Tk. 2345 of which Tk. 4000.00 is the highest and Tk. 800/month is the lowest. About 58.6% were income earning.
Mean income earning of respondents were Tk. 1306, whereas, Tk. 3000.00 and Tk. 500.00 were the maximum and the minimum. About 86.2% lived in own houses. About 75.9% were living in thatched houses. Only about 13.8% had good road communications. About 55.7% have no tube wells or electricity in their houses, whereas, 39.4% and 20.4% have tube wells and electricity respectively in their houses.
About 36.1% husbands were illiterate. About 54.8% wives were illiterate.
The respondents were interviewed for Knowledge, Attitude and Practice (KAP) as the social factors mentioned affect the mind of the individual and thus affect their behavior through their knowledge. From knowledge through attitude they become involved with their practices, thus acquires the behavior. About 48.3% had no knowledge of any UHC/MCWC nearby, 51.7% had. None informed of regular contact with the government hospitals for treatment, 27.6% never went GoB outlets for treatment, 72.4% go occasionally. Only 6.9% expressed their satisfaction in Government facilities. A About 89.7% expressed their dissatisfaction for GoB hospitals.
About 82.8% informed “no medicines available” as their reason for not going to GoB hospitals (anyone) for treatment, whereas, 65.5%, 44.8% and 41.4% informed of their reasons as the absence of doctors, bad road communication for going for treatment and “bad” behavior of the doctors respectively. All (100%) informed of quack/non-MBBS private doctors as the service outlet for the treatment of their family members, whereas, 82.8% informed both of religious/spiritual healers and Homeopath/Kabiraji/traditional healers for the same indicating the strong affinity of the rural population of Bangladesh for medieval treatment procedures for different reasons. Curiously NGO outlets had been described for the same by only 6.9% of the respondents. Among the interviewed respondents, all (100%) respondents described “low cost treatment” as the reason to select treatment outlets for the family members. Again 58.6% and 51.7% respondents described the reasons as “treatment facilities always available” and “nearer to the patient's house” respectively. About 44.8% respondents accounted for “treat with care and listen/counsel well” as the reason for the same. Among the interviewed respondents, only 17.3% expressed their satisfaction in treatment wherever they get that. Curiously interesting is the finding is that, a vast majority of 82.8% remained “unsatisfied” with treatment, even in their outlets/hospitals of choice for the treatment of their family members!
Among the interviewed respondents, 75.9% disclosed their reason for dissatisfaction as “Needs time to cure/can’t diagnose properly”, whereas, 51.7% for “high fee”, 41.4% stated their reasons of dissatisfactions for both “requires repeated visit” and “frequently prescribing injection/I.V. saline”. About 31% described their reason for dissatisfaction as “bad behavior of the doctors and staffs of the hospitals”. Among the reasons for satisfaction, “see the patients with care” and “good treatment” accounted for 17.2% and 6.9% respondents respectively. Among the interviewed respondents, 93.1% believed the etiology of disease as “from the anger of Allah/God”, whereas, 65.5% thought the etiology as “from infection by germs”. About 41.4% informed of “other” reasons as the etiology i.e. “dissatisfaction of gods”, “dissatisfactions of the nymph” etc. Among the interviewed respondents, 72.4% informed of providing first aids in home for patients, whereas, 27.6% informed of not providing first-aid in home. Among the interviewed respondents, 65.5% informed that the female chiefs of the corresponding families had supervised the family first aid. Only 17.2% informed that the male chiefs did it. Another 17.2% informed of the supervision by others like other family members etc. Among the interviewed respondents, 93.1% expressed their beliefs in traditional/folk medicine, whereas, the rest 6.9% informed of their no belief in traditional/folk medicine. Among the interviewed respondents, all (100%) respondents stated “green coconut water/ liquid /ORS/ laban-gur preparation (salt-molasses solution)” as the traditional/folk or indigenous treatment of diarrhoea, whereas, 93.1% respondents informed of the “holly water/talisman/exorcism” as the as the traditional/folk or indigenous treatment of diarrhoea. “Herbal extracts/herbs” accounted for 31%, whereas, unfortunately another 51.7% and 24.1% of the respondents opted for “heals spontaneously” and “closure of feeding” respectively indicating existence of potential grave public health risk in the issue still prevailing in the rural Bangladesh regardless the highly advertised optimistic views of government and many NGOs. Among the interviewed respondents, 96.6% described “massaging warm oil/garlic-warm oil in chest” as the traditional/folk treatment for the respiratory infections including pneumonitis in the rural Bangladesh. About 72.4% opted for “ingesting tulsi/other herb extracts”, whereas, 48.3% and 31% had opted for “drinking honey with or without hot water” and “eating onion-rice” respectively. About 10.3% opted for “spontaneous healing” signifying potential public risk in the disease still prevailing in rural Bangladesh. Among the interviewed respondents, it was curiously unveiled that 62.1% stated the traditional/folk treatment or remedy of RTI/STD as “coitus with virgin/fresh women”! Again 55.2% described “ingesting herbal extracts” as the traditional/folk treatment of RTI/STD, whereas another 69% had opted for “ingesting country elixirs (Saribadi salsa etc). Only 34.5% and 20.7% had been accounted for the more scientific approaches like “irrigating/washing genital organs with saline” and “drinking excess of water” respectively. However, 34.5% opted for potentially risky “heals spontaneously”. Among the interviewed respondents, 89.7% opted for “holy water or talisman” as the traditional/folk remedy of abortion, whereas 79.3% depends on the “exorcism and different religious rites” as the traditional remedy for the same. Again 37.9% stated on behalf of “ingesting herbal extracts/Kabiraji /salsa” as the remedy. However, 48.3% opted for alarming “heals spontaneously”!
38. Among the interviewed respondents, 72.4% opted for “eating rice with herbal preparation’ and also another 69% described “ingesting herbal extracts/elixirs” as the traditional/folk remedy of jaundice. “Exorcism/religious treatment” as the remedy of jaundice opted by 51.7% respondents, whereas, 37.9%, 24.1% and 37.9% informed of “bathing under supervision of a holly man”, “applying herbal pulp on the body and head” and “wearing sanctified talisman/necklace/wristband” respectively as
the traditional or folk remedy of jaundice. Whereas, the scientific approach “ingesting sugar cane juice” practiced as remedy of jaundice by only 3.4%. Among the interviewed respondents, 96.6% described the traditional or folk remedy of hysteria through “exorcism/religious treatment/religious rite”, whereas, 86.2% stated the remedy as “through use of “holly water/talisman etc.” Curiously interesting that 48.3% opted for “smelling burn chilly in the nostrils” as the remedy for hysteria. Again 6.9% described the remedy as “goddess Kali's worship”! Among the interviewed respondents, 75.9% described “exorcism/religious treatment” as the traditional remedy for mental retardation. Again another 82.8% opted for the use of “holly water/talisman” as the traditional or folk remedy for mental retardation in the rural Bangladesh. Remedy through spontaneous process had been described by 51.7% of the respondents. “Kali sadhan or special rite to satisfy the nymphs had been prescribed by 6.9%, whereas, 17.2% opted for praying to Allah/God for the remedy.
Among the interviewed respondents, 79.3% stated that they feel shyness to be treated (going to doctor, telling to the family members about the disease etc. Among the interviewed respondents, 89.7% feel guilty if diseased/possesses stigma if diseased. Among the interviewed respondents 68.97% believed the disease as the punishment from the Allah/God. Among the interviewed respondents, 93.1% described “ingesting rotten/decomposed/contaminated” as the etiology of diarrhoea/Cholera/Bhedbami, whereas, 51.7% informed of “if anybody special watches pt. to eat” as the etiology of diarrhoea/Cholera/Bhedbami. Curiously interesting “anger of scheduled local goddess Ola/Obba” and “Eating in odd time” had been suggested by same proportions of the respondents (34.5% for the both) and respectively. “Night/noon traveling after eating palm cake” was stated as the cause by 31%. Among the interviewed respondents, all (100%) described “getting cold” as the etiology of respiratory infection. “Becoming wet in rain/exposed to open space” and “Staying with a patient of cold/cough” both were described as the etiologies by 72.4% of the respondents for the same.
Among the interviewed respondents, 79.3% described going to "bad" places/coitus with prostitute or unknown person as the etiology of reproductive tract infection and sexually transmitted disease. About 51.7% informed of “sexual partner/self/staying unclean/dirty” as the etiology of the same. Pretty high percentages expressed their various superstitions as the etiology of reproductive tract infection and sexually transmitted infection. Among the interviewed respondents, 72.4% claimed “coitus in pregnancy/repeated coitus”. “Eating/drinking/herbal foods/extracts” and Inflicted with unseen influence of black magic”, both stated by 51.7% of the respondents as the etiologies of abortion in rural Bangladesh. Claims like “Eating pineapple/leaf/papaya/carrot” had been described respectively by 41.4% respondents. Among the interviewed respondents, 79.3% and 72.4% claimed etiology of jaundice as “possession by scheduled goddess (pachu-Pachy)” and “black magic/ban or witchcraft or deploying evil power” respectively. Staying in the wet places”, “Ingestion of excessive turmeric in food/working in the turmeric field”, “attending turmeric day in a marriage ceremony” etc described as etiology by appreciable percentage of respondents. Among the interviewed respondents, 75.9% and 72.4% claimed “possession by spirit of dead died unnaturally” and “possession by supernatural/evil power” respectively as the etiology of hysteria. All the responses seemed to be linked with their traditional myths. Among the interviewed respondents, 58.6% and 48.3% claimed “possessions by supernatural/"evil" power” and “black magic/witch craft/deploying evil force” respectively as the etiology of mental retardation. Mythical “going outside in kali goddess night (Kali puja)” claimed by 37.9% as the etiology of mental retardation. It is surprising that very few admitted that they did not know the scientific etiology and nobody were reluctant to tell something as etiology of “mental retardation”. Among the interviewed respondents, 82.8% claimed the etiology as “fed with unconventional meat (of vulture, crow, fox etc)” and 69% claimed “possession by supernatural/"evil" power” as the etiology of madness. “Possession by the spirits of dead died” comes here as etiology stated by 55.2% respondents.” Black magic/witch craft/deploying evil” and “Going outside in kali goddess night (Kali puja)” claimed by 44.8% and 31% respondents respectively as the etiology of madness. Among the interviewed, 89.7% sated for the both “harm by different religious/spiritual rite” and “harm through witchcraft” as the etiology of “Ban”! About 79.3% respondents claimed and justified etiology of their “ban” respectively as “black magic with hair, nail/cloth of victim”.
Among the interviewed respondents, 100% and 89.7% claimed “doing harm by religious/ kali goddess rites” and “Black magic with hair, nail, cloth of victims” respectively as the etiology of black magic. Interestingly, 6.9% and 3.4% described the etiology for the same as “others” and “impelling a doll for the victim (Voodoo)” respectively which resemble closely with West Indian or African Voodoo black magic. Among the interviewed respondents, 72.4% and 58.6% claimed “travel in inappropriate places in odd time” and “night travel through the place of cremation” respectively as the etiology of the “evil air”. Goddess Kali again blamed for 41.4% response as the etiology of “evil air”! Among the interviewed respondents, interestingly 62.1%, 65.5% and 34.5% claimed etiology of “fearfulness” as “being afraid by any means”, “going outside or travel in night of new moon” and “seeing cat or dog in village road or bush in night” respectively. Goddess Kali puja night scored 37.9% response among the people of all religion in rural area of Bangladesh.
Among the interviewed respondents, about 41.4% and 37.9% opted for “quack/non-M.B.B.S. private doctors” and “private M.B.B.S. doctors” respectively for treatment if have sufficient money. Interestingly “government hospitals” accounted for only about 10.3% respondents reflecting rural people’s attitude to these outlets.
Among the interviewed respondents, 82.8% and 79.3% informed of the disease cured by Allah/God’s wish and through proper treatment respectively. About 31% described healing spontaneously indicating misconception related to grave public health risk.
Among the interviewed respondents, it is of particular interest, 93.1% informed that their source of health information (whatever the qualities) is “imam/priest/religious personality”, whereas, 34.5% described “government health workers” for it. Also of interest that NGO contributed only for 6.9% as the source of health information.
Among the interviewed respondents, about 41.4% described “private M.B.B.S. doctors” and about 34.5% informed of “Quack/non-M.B.B.S. private doctors” as the best treatment providers. However, only about 13.8% thought “Government hospital” as the best treatment providers.
Among the interviewed respondents, about 96.6% expressed their dissatisfaction in treatment in government hospitals in general.
Among the interviewed primary respondents, 69% informed their cause of dissatisfaction as “behavior of the doctors/staffs in government hospitals is not good and less care”. About 58.6% were dissatisfied because of unavailability of required medicines, whereas 62.1% showed their dissatisfaction due to absence of doctor in the outlets/hospital. However, only 3.4% respondents are satisfied in government hospitals putting reason of having best doctors there.
Among the interviewed respondents, about 55.2% admitted that the disease could be healed through spiritual means. However, about 44.9% did not agree in the issue.
Among the interviewed respondents, about 89.7% thought male’s permission was necessary for the treatment of female family members.
Among the interviewed respondents who supported the view of male’s permission for female’s treatment, about 38.5% respondents put the cause as “males are the head of the family”, whereas about 23% put the cause as “Males are income earning ”. However, about 7.7% did not know why they advocated for the male’s permission!
Mean expense for the treatment of diarrhoea was notified as about Tk. 70 where minimum and maximum were Tk. 50 and Tk. 100 respectively.
Mean expense for the treatment of pneumonia/grave respiratory infection was notified as about Tk. 180 where minimum and maximum were Tk. 90 and Tk. 250 respectively.
Mean expense for the treatment of Reproductive Tract Infection (RTI)/Sexually Transmitted Disease (STD) was notified as about Tk.266 where minimum and maximum were Tk. 100 and Tk. 400 respectively.
Mean expense for the treatment of abortion was notified as about Tk. 591 where minimum and maximum were Tk. 150 and Tk. 1000 respectively.
Among the interviewed respondents, about 72.4% respondents informed that they were never keen for modern treatment for jaundice!
Among the interviewed respondents, 93.1% opted for “homeopath/Kabiraji/traditional healers” if got jaundiced! Again, the rest 6.9% disclosed their desired treatment centers/healers as “religious/spiritual healers” if become jaundiced!
Mean expense for the treatment of jaundice was notified as about Tk. 340 where minimum and maximum were notified as Tk. 200.00 and Tk. 500.00 respectively.
Among the interviewed respondents, about 75.9% respondents expressed that they were never keen to be treated with modern medicines for “mental retardation”, whereas, only about 13.8% opted expressed their occasional keenness for modern treatment for mental retardation.
Among the interviewed respondents, about 74.4% opted for treatment outlets with religious or spiritual healers for the treatment of mental retardation, whereas, only about 3.5% described their choice in favor of government hospitals for the treatment for the same disease.
Mean expense for the treatment of mental retardation was notified as about Tk. 347 where minimum and maximum were notified as Tk. 100 and Tk. 500 respectively.
Among the interviewed respondents, about 79.3% stated that they were never keen for modern treatment in hysteria, whereas, only about 10.3% opted for modern treatment for the same disease!
Among the interviewed respondents, about 72.4% described “religious or spiritual healers” as their chosen treatment outlet for hysteria, whereas, about 24.1% opted “quack/non-MBBS private doctors” as the outlet for the same disease treatment. Government hospital was chosen by about only 3.5% for the purpose.
Mean expense for the treatment of hysteria was notified as about Tk. 248 where minimum and maximum were notified as Tk. 100 and Tk. 500 respectively.
Among the interviewed respondents, about 82.8% were never keen for modern treatment for “madness”. Only about 3.5% opted for “frequently keen treatment” for “madness”.
Among the interviewed respondents, about 65.5% opted “religious/spiritual healers” as the outlet for the treatment of “madness”, whereas, only 3.5% opted “government hospitals” for the same.
Mean expense for the treatment of “madness” was notified as about Tk. 441 where minimum and maximum were notified as Tk. 150 and Tk. 600 respectively.
Among the interviewed respondents, about 86.2% stated that they were never keen for modern treatment for “ban”.
Among the interviewed respondents, about 82.8% had their desired outlet as “religious/spiritual healers” for “ban”, whereas, 6.9% relied on “homeopath/Kabiraji/ traditional healers”.
Mean expense for the treatment of “Ban” was notified as about Tk. 407 where minimum and maximum were notified as Tk. 100 and Tk. 700 respectively.
Among the interviewed respondents, about 89.7% respondents were never keen for modern treatment of “black magic” or “witch craft”.
Among the interviewed primary respondents, about 79.3% respondents opted for “religious/spiritual healers” as their treatment outlet, whereas, about 13.8% relied on “quack/non-M.B.B.S. private doctors” as treatment outlet for the described disease.
Mean expense for the treatment of "black magic" or "witchcraft” was notified as about Tk. 428 where minimum and maximum was notified as Tk. 100 and Tk. 700 respectively. Among the interviewed respondents, about 86.2% were not keen for modern treatment of “evil air”.
Among the interviewed respondents, about 82.8% opted for “religious/spiritual healers” s the desired outlet for the treatment of “evil air”, whereas, only about 10.3% opted for “quack/non-M.B.B.S. private doctors” and nobody opted for government hospital for the same.
Mean expense for the treatment of "evil air” was notified as about Tk. 238 where minimum and maximum was notified as Tk. 100and Tk. 400 respectively.
Among the interviewed respondents, about 89.7% were never keen for modern treatment for “fearfulness”.
Among the interviewed primary respondents, 87% opted for “religious/spiritual healers” as desired outlet for treatment of “fearfulness”, whereas, about 13.8% opted for “quack/non-M.B.B.S. private doctors” as treatment outlet for the same disease.
Mean expense for the treatment of "fearfulness” was notified as about Tk. 163 where minimum and maximum was notified as Tk. 60 and Tk. 300 respectively.
Among the interviewed primary respondents, about 58.6% respondents described the above treatment costs as “not justified”. A significant proportion (about 27.6%) responded as “don’t know”!
Mean transport cost of the patient to nearest hospital was notified as about Tk. 44 where minimum and maximum was notified as Tk. 30 and Tk. 60 respectively.
Among the interviewed respondents, about 58.6% informed of their minimal required time for transferring the patient to nearest hospital as less than 3 hours, whereas about 34.5% informed that as more than 3 hours.
Among the interviewed respondents, about 62% thought that "health problems" and diseases are not same (if not same, then there were scopes for trying remedy otherwise than the treatment! i.e. disease: more grave condition, problem: less grave condition, so for the less grave condition, they can call traditional or spiritual healers for low costs mainly).
Among the interviewed primary respondents, 93.1% respondents thought that the GoB doctors were “not enough dutiful and sincere” with the patients.
Among the interviewed respondents, about 58.6% perceived the “treatment environments in the GOB hospitals” as “not good”, whereas, about 27.6% responded as “don’t know”.
Among the interviewed respondents, about 75.9% thought that GoB doctors “don’t listen/counsel well the patients” coming for treatment to the government hospitals. Again, about 10.3% thought that the GoB doctors “listen and counsel well the patients” when they were paid with money! (Taking money is out of rule for the doctors in Government hospitals and this response showed the situation in the Government hospital!)
Among the interviewed respondents, about 65.5% respondents admitted that the diseased person were experiencing abusing for disease, whereas, 6.9% don’t know anything regarding the issue.
Among the interviewed respondents, who admitted as above, about 47.6% thought it was “because of the expenses of treatment”, whereas, about 14.2% described the causes as “because of interruption in income earning/study” and “Because of interruption in income earning”.
Among the interviewed respondents, about 65.5% respondents thought that the family could decline to treat its patients even having capacity for that.
Among the interviewed respondents, who admitted the above, about 50.6% thought the cause as “for expenses of treatment”, whereas, about 26.3% thought the cause as “lack of awareness/failure to perceive importance”.
Among the interviewed respondents, about 17.2% thought that they had “mental patient” within the family.
Among the interviewed respondents, who thought of having “mental patient” within the family, nobody could tell the exact prevailing disease (didn’t know what is exactly the disease was!).
Among the interviewed primary respondents, who thought of having “mental patient” in the family, 40% were treated with any means.
Among the interviewed respondents, 89.7% opted for “religious/spiritual healers” as the outlet for the treatment of “mental patients”, whereas, 65.5% voted for “quack/non-M.B.B.S. private doctors” as the chosen outlet for the purpose. However, the government hospitals accounted for 62.1%.
Among the interviewed respondents, about 51.7% described the cause for the above choice as “psychological diseases can’t heal by modern treatment” whereas, about 37.9% described that as “that healers were good for mental diseases”!
Among the interviewed respondents, about 86.2% thought that the psychological diseases could not be cured fully, even with proper treatment!
Among the interviewed primary respondents, 89.7% thought “possession by supernatural evil forces” as the etiology of “madness”, whereas, 65.5% thought that as “black magic/ban/witch craft/devil worship”. Curiously interesting that “mental shock” contributed for 10.3%, goddess Kali for a considerable proportion of 44.8% and “fed unconventional meat/drinks (kite/vulture)” for massive 44.8%.
Among the interviewed primary respondents, 82.8% thought “possession by supernatural evil forces” as the etiology of hysteria, whereas, 58.6% that for “black magic/ban/witch craft/devil worship”. “Mental shock” contributed for 6.9% and goddess Kali for 24.1%. “Bad wind” scored 69% for the disease!
Among the interviewed respondents, 58.6% admitted their lack of knowledge regarding etiology of “non-responsiveness”, whereas, 41.4% thought the etiology of the disease as “possession by supernatural evil forces”. “Bad wind”, unconventional meat and “mental shock” contributed for 34.5%, 34.5% and 6.9% respectively.
Among the interviewed respondents, 69% thought “possession by supernatural evil forces’ and 65.5% “mental shock” as the etiology of “mental depression”! “ Black magic/ban/witch craft/devil worship” contributed another 37.9% and goddess Kali for 17.2%. However, 27.6% didn’t know anything regarding the etiology of “mental depression”!
Among the interviewed respondents, 75.9% confirmed “possession by supernatural evil forces” as the etiology of “agile’, whereas, 65.5% thought that was caused by unconventional meat. “Black magic/ban/witch craft/devil worship” and goddess Kali contributed for 44.8% and 31% respectively as the etiology for the disease.
Among the interviewed respondents, each 93.1% described their outlet for RTI/STD treatment as “homeopath/Kabiraji/traditional healers” and 82.2% each for “religious/spiritual healers” and for quack/non-M.B.B.S. private doctors for the purpose. Only 41.4% opted for government hospitals for their treatment of RTI/STD.
Among the interviewed primary respondents, about 82.8% thought that somebody didn’t take treatment for RTI/STD as because that could be healed spontaneously, whereas, another about 17.2% thought that actually they had been treated through somebody else who contacted doctors/healers on behalf.
Among the interviewed primary respondents, about 65.5% had patients (of any disease) in the family (Point Prevalence of Disease).
Among the interviewed primary respondents, who had patient in the family, about 21%, about 15.8%, and about 26.3% had diarrhoea, jaundice, and respiratory tract infection respectively as prevalent diseases.
About 52.6% respondents informed of their duration of sickness more than a week, whereas 10.5% had the duration of sickness as more than 15 days.
About 84.2% respondents who suffered from any disease informed that they were treated for the mentioned diseases
About 43.8% respondents informed of their treatment through “Quack/non-M.B.B.S. private doctors”, whereas 25% respondents did that through “Homeopath/Kabiraji/traditional healers”.
About 75% respondents those were not treated correctly (as perceived by the qualified doctors)
The main conclusion is i) certain social factors affect the mind of the individuals (among the rural population in the Rajshahi Division) and develop/shape their health care behavior manifested in their practices in response to any disease condition ii) economical condition, gender, religion, availability of the options and traditional beliefs etc. are the major factors that affect mind of the individual for his/her response/behavior for health care iii) despite found some practices reflecting modern and scientific knowledge, the respondents among the rural people of Rajshahi possess health care behaviors according to their traditional beliefs mostly and certain factors like poverty, illiteracy and lack of options etc. aggravate their tendency for mentioned health practices. They were found to be involved in century old superstitious health practices in response to diseases iii) it is necessary to bring positive changes in their in their health care behaviors and for that the underlying factors should be dealt with.
The mission of this research study was to explore the whereabouts for rural Bangladesh and more specifically for rural Rajshahi Division of the social factors related with the health care behaviors of the population.
After examinations of the findings yielded from the carefully designed data collection instruments, it was seen that regardless the vast advancement in science and civilization, health care behaviors and practices in rural Bangladesh, i.e. in rural Rajshahi Division still remained medieval in many contexts.
Certain social factors, especially the extreme poverty, over population, low literacy rate and high degree of superstitions, local tales, myths, legend, traditional knowledge and practices, all obstructed desirable progress and development and hindered appropriate modern health practices. Findings of the study documented the facts mentioned.
Development of a behavior is always a long process which continually receives its necessaries from the community. No doubt, rural Bangladesh, or rural Rajshahi Division surely achieved progress in many contexts, even in many compartments within the same context like health service, but there remain many unmet needs. Specifically in the context of health service, there are many such left still.
A good and successful health situation must comprise of i) availability of quality health service ii) positive health care behavior of the population for health seeking. For component no. i), state should have the prime responsibility and for the component no. ii), positive health seeking or care behavior should be developed by the joint efforts of the state and the community.
Health care behaviors of the studied population were developed and practiced mostly on their i) knowledge of the specific disease or health ailments ii) their perceived etiologies of those diseases, iii) financial capabilities and iv) the availabilities of the proper options within their reach etc. Explaining the issues as follows might help us for easy understanding:
Now, this contained knowledge of the population is dependent on the traditional beliefs, religious superstitions, local myths, tales and legends. These are the elements responsible for their mindset for health care behaviors or actually how they will behave for their health for any health ailment or disease. Exploration of these elements through KAP revealed information.
Perceived etiologies of the specific disease always play a major for developing specific health care behaviors and practices for those diseases. In this research study we saw that the health care behaviors and practices were related to their etiologies mostly.
Financial condition is an important determining factor in development of any behavior. The people will be not agreed to do anything as their health care behavior which will be out of their financial capacities. Nor the service providers will tell them anything that will be out of the financial capacities of the service seekers as they know), if they tell something out of the financial capacity of the service seekers, the service seekers will leave them and may go to other places for seeking that health care services! So, any health care behavior resulted practice is the mutually settled incidence between the service providers and seekers.
Availability of option: If diseased, people require availabilities of options within their reach. So, even they are interested to take proper treatment and if that treatment is not available in the vicinity, then they will be not able to exercise their positive health care behaviors.
As we saw in the findings of the study, “shame” is frequently associated with the feelings of “guilt” and the stigma and in the case of health care behaviors; it is the feeling of guilt and stigma due to be diseased which predisposes to the development or modification of their health care behavior.
Here again we find the interesting information as previously when the vast majority of the respondents informed that the Government doctors were not listening/counseling well the patients and a relatively lower proportion informed that those doctors were listening and counseling well when paid extra by the patients! So, how this could affect health care behaviors of people? There were variable degrees of possibilities as follows:
i) As the Government doctors “listen and counsel well” if paid, the people will develop the health care behavior to go to Government doctors if get that amount of money with them.
ii) They could develop the health care behavior to go to the Government doctors, if the degree of sickness is grave and there were no other alternatives
iii) They could go to the other cheaper service providers if not have sufficient money for the fee of the Government doctors
iv) In some cases, they might neglect the treatment procedures of the disease as it could cost high.
Above are the different variations of the health acre behaviors which can be developed in response to the mentioned situations.
At last, it can be told that health care behavior is a very complicated human behavior which originates gradually through various processes in the community depending on the knowledge of the population where financial ability is the most important factor.
It can’t be told very openly in the community that all the traditional practices are harmful (as that may affect the community people), but should be carefully examined.
Recommendations:
i) Appropriate and effective public health delivery system is a burning need in the rural area under Rajshahi division.
ii) Appropriate steps should be taken for poverty alleviation and increase Income Generation Activities in the households for the rural areas under Rajshahi Division.
iii) Participatory and community based inter-sectoral Behavior Change Communication (BCC) program in health should be launched in health with Information, Education and Motivation (IEM) for disseminating modern health knowledge among the rural population under Rajshahi Division. Religious personalities, community elites and traditional healers must be communicated with modern health knowledge.
iv) Training programs should be arranged for the village doctors, paramedics, pharmacy salesmen and other grassroots health service providers on primary health care by Government and NGO.
v) Existing Government (Upazilla Health Complex, Union Health Complex, Family Welfare Centers and community clinics etc.) and NGO health service facilities should be ensured with appropriate logistics and manpower (medicines and medical doctors etc.). Government public health department and local elected bodies can monitor the presence of the manpower and logistics in all health facilities of the area. NGO affairs bureau can look after new NGO programs and donors in health for the area.
vi) Private and NGO entrepreneurships should be encouraged and facilitated in the area for establishment of Out Post Dispensaries (OPD) and Satellite Clinics.
vii) Steps should be taken for total sanitation and safe drinking water supply for the area, deploying Government and NGO efforts.
viii) More behavioral research studies are required as sufficient number of behavioral studies is lacking in Bangladesh to find sufficient number of secondary data when required for designing research studies and programs.
ix) As this study was basically a generalized study, so only limited scopes could be made available for exploring deep of the many interesting issues due to mandate constraints. In every stage, the researcher felt necessities for the more in-depth studies. The unveiled/revealed interesting issues in the process and outcomes of the study should be explored sufficiently, so more studies are required. Emphases should be given for studies in much specified sub-contexts like reproductive health behaviors in general, in gender and among different socio-economic and anthropological groups. Also studies on health seeking behavior in respect to genders etc. are the required.
x) Piloting project can be designed with the findings, data and experiences from the study and can be launched to document the success and the failures by the Government and NGOs working in the relevant fields.
xi) The findings can be considered and utilized by the different level policy makers in Government and NGO sectors to compile/modify their policy.
xii) Findings can be considered and utilized as Performance Improvement (PI) tools by the authorities responsible for health service deliveries in the rural areas for desired performance improvement of the prevailing Government and NGO health service delivery programs.
xiii) Certain information unveiled in the findings of this study can be utilized for advocacy purpose to influence the policy makers by the NGOs.
Although there were scattered mentioning of different facts about the health care behaviors of the rural population of Bangladesh through their possessed knowledge, attitudes and practices in response to different disease conditions and related contexts, huge gaps were perceived for a systematic and detailed documentation while reviewing the literatures in the context of the present study. The knowledge existing was found to be non-systematic and insufficient in different contexts like those for the rural population, especially for Bangladesh. Even a few people from the metropolitan cities knows actually what is happening in context of health care services in the rural areas of Bangladesh as there is no documentations and no reliable information. Also most of us know very little about the knowledge, attitudes and practices of the rural populations in details in the context of their health seeking.
In fact, most of us, the elite society of Bangladesh usually don’t stay or stay for little time in rural areas as we usually live in the metropolitan cities or in District or Thana headquarters. So, our chances to perceive the rural dynamics of health care behavior are very limited. Again those may appear to us as normal as we are accustomed to see those. We rarely investigate the underlying.
Again the Government and non-Government responsible quarters for the health services in the rural areas of Bangladesh are producing reports which have questionability and most of the time they produce plenty of success stories having no relations with the situations in the ground. For the reports to the national level bodies and to the donors, documentations are frequent highlighting the successes. Unfortunately, the actual facts in the rural areas remain untold and thus as most of the program designed on the untrue or fabricated facts, the programs ultimately fail and the `need of the people remains un-mate!
For the reasons mentioned in the objectives, rationale and in other sections, systematic and detailed facts about the rural people’s health seeking behavior in the rural Rajshahi, thus in rural Bangladesh was a requirement to be added as a new component with the existing knowledge in the context, systematic documentation of enormous information revealed by present study fulfilled that objectives to an extent in my opinion.
The study yielded and documented varieties of information about the existing knowledge, attitudes and practices of the rural population in Rajshahi Division in the contexts of their health care behavior. The study investigated and explored the traditional beliefs, indigenous cultures, religious taboos, social norms, existing rituals etc. and their reflections in the operational knowledge, attitudes and practices People of the rural areas of Rajshahi Division expressed their contained knowledge about the etiologies of different diseases common in rural areas of Bangladesh which is very much important to understand their decision making process to choose the types treatments. That is again of cardinal importance to design any Behavior Change Communication (BCC) for them to make differences.
The study also reflected the underlying causes those influences their decision making processes to choose different types of managements.
The study explored and documented various imaginations and beliefs existing in the rural population of Rajshahi division in the contexts of the diseases, their etiologies (developments) and their managements and those will be added with the existing knowledge about the rural population of Rajshahi Division and Bangladesh.
The study also explored and documented their existing practices in response to disease and the knowledge will be added with the existing knowledge in the contexts for the rural population of Rajshahi division and also for Bangladesh.
Thus, the information revealed by the study bridged the previous knowledge gaps in the mentioned context to an appreciable extent.
= they are not real Khastrio who are rare in East Bengal or Bangladesh. Real Khastrio are the martial race of the Hindu religion and use to be the rulers, fighters etc. and the Rajputs and other north Indian castes are known as Khastrio. Population in the northern Bengal indenifies them as Khastrio for some mythical reasons that were introduced by their kings like king Bishwashor of Kuch kingdom. According to the myth, Pandob Arjun came to this land and married the indigenous princess Chitrangada. Arjun was the top most Khastrio of the era, hence the Kuch king define themselves as the Khastrio. Typical Khastrio likely to have pure Aryan builds, whereas these Pundro- Khastrio are of Mongolian origin without doubt in their body and skull builds and in appearances!
2= Other than the Muslims, all counted as the Hindus)
2. Rangpur Sadar Upazilla was accounted for the highest number of interviews (71.8%), Rajar Hat and Ulipur Upazilla, both within Kurigram District, were accounted for about 14.4% and 13.8% interviews respectively. For the same reason mentioned above, Sadar Upazilla of Rangpur District accounted for highest number of respondents and two Upzillas of Kurigram District were accounted for the rest of the sampled respondents.
3. Uttam Union of Rangpur Sadar Upazilla was accounted for the highest number of interviews (71.8%), Chhinai Union of Rajar Hat Upazilla and Pandul Union of Ulipur Upazilla, both within Kurigram District, were accounted for about 14.4% and 13.8% interviews respectively. Sampled Unions were accounted for mentioned sampling.
5. About 6.6 % respondents were from East Para of the Goalu village, where as other Paras of Goalu namely West Para, Khayan and "other" Paras accounted for 10.1%, 16.1% and 14.7% respondents respectively. Paras in the village Bahadur Singha accounted for 13.5% of the interviewed respondents. Mollah Para, Kamar Para and Char Joy kumar accounted for 10.9%, 6.9% and 7.2% respectively.Random/systematic random sampling techniques have been used (details in the sampling technique chapter).
7. Mean age of the respondents interviewed was 44.4 years. The highest aged respondent interviewed was/were of 62 years and lowest of 30 years. The ages of the respondents were between 30-62 years. These are the ages in which a respondent can be mentioned as of normal age of knowledge and capable of understand and disseminate any information normally.
8. Among the interviewed primary respondents 8.9% was Pundro-Khastrio/Rajbanshi/Kuch1. About 74.4% and 4.3% was Muslim and general mainstream Hindu, Bairagi/Nath-hath-yogi/Baisnab2 and the Khyan were accounted for 5.2% and 7.2% respectively. It is interesting that although the mentioned population claim that they belong to the religion of Hindu, the mainstream of the Hindus have been continually refuse to admit the claim. In the observation at the field, it was seen that most of these unconventional Hindus are the descendants of the ethnic aboriginals, mostly the mongoloids anthropologically i.e. mostly possibly from Garos. Moe or less, it is the same scenario in everywhere of the rural population of Bangladesh, where this scheduled Hindus constitute a considerable portion of the total Hindu population of the area. 
9. Among the interviewed primary respondents, 44.5% were illiterate and 55.5% respondents were claimed to be literate. Again about 32.2% respondents interviewed were literate to the extent of primary level. Only 5.7% respondents interviewed were educated up to the S.S.C. level and above. Reflecting the situation in rural Bangladesh as a whole in the context of education. Only 5.7% SSC level education leaves the rural Rajshahi areas extremely vulnerable to superstitions and obstructs positive changes in the contexts of any modern and scientific knowledge and practice among the population.
10. Among the interviewed primary respondents, about 34.5% accounted for number of family members as 4, whereas about 17.2% have 8 member families. About 24.2% have family members more than 6. Only about 3.5% have families with 3 members. Expresses the excessive population in the rural areas and the family size in the households which is important to any design for health delivery system in the study population.
9. Among the interviewed primary respondents, about 29.3% belonged to the agriculture as their occupation, whereas about 46.6% were the housewives. About 8.3% were different professional groups. As we saw in previous table analyses, more than half of the respondents (51.7%) were females and here it is seen that about 46.6% of the total respondents are housewives. So, some of the females respondents had been doing something other than their roles as housewives.
10. Among the interviewed primary respondents, about 65.5% respondents’ economical condition was assumed as "not good". Only about 10.3% were identified having "good" or well off economic conditions. (Dresses, household utensils and other assets were indicators for the assumption). As the interview process was totally participatory and community based, interviewers were deployed from the community and they applied their indigenous techniques as they usually use to describe the economical conditions in their community and no highly precision scaling system was used due to the nature of the interviews. They could do it most preciously as the researcher thought. Economic conditions were predicted by the interviewer on certain general findings/criteria. How they pass their lives, what they eat, what they wear and what they do for income earning. Also idea was taken by observing their household for built and other criteria. This is the general understanding of the economic condition expressed in their livelihoods, not a very technical analysis and in most cases, it fulfills the objective to understand population’s situation. No strict economic measurement scale from any institute has been used, rather assumptions have been made with the indigenous idea found in the locality among the population to tell some one having "good", "average" or "not good" economic condition and those are dependent on the livelihood indicators of the assessed families or households (this is common practice in the rural Bangladesh to describe anyone’s economic condition)
17. Among the interviewed respondents’ families, about 13.8% live in houses with good road communications and 41.4% with average road communication. About 44.9% has the household with bad road communications. Here only 13.8% respondents, who live at the side of the highways and other subways, stated they had good road communications. Other stated it as "average" or "bad". Road communication has a great role in the health seeking behavior as people have to go to the service centers through the roads. However, not only the road, also the transportations are required, and in most good roads, some types of transportations are present.
